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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT LY. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)x 06-67$}' /)0 q ``"-k P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.' Job Addressl Cii -& Lot Size '9cee, PM Owner's Name Address /' Phone Contractor .�li/! � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ^I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ l INTENDED USE TYPE OF WELL PROBLEM AREA.f CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 17 Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigationi -Apprax,-Depth l I Eastern Surface Seal Installed by 1 Repair Work Done LJ Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material {top 50') I Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION ki!N septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK T Mfg':L OM 1,47' Capacity,/. �2C)O. No. Compartments r PKG. TREATMENT PLT. ❑ 11Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth 3 size Number SUMPS ❑ Distance to nearest: Well Foundation r Property line DISPOSAL PONDS 0 1 P I I hereby certify that I have prepared this iapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin'Local Health District. i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not f employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ! The applicant m t call for all required inspections. Complete drawing on reverse side. Signed XTitle: ur r� s Date: - i 1 FOR pEPARTMENT USE ONLY Application Accepted by Date qr I Pit or Grout inspection by Dat / Final Inspection by pa /may Additional Comments: �fi �` I `r _ 5 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED 1 INFO k ASH RECEIVED BY DATE // �JPPEEE MIT'NO. �y 1 + EH 14-28(REV.I/rs 5) A// +p (J(/ a�! { .